- Associated Press - Saturday, August 2, 2014

PITTSBURGH (AP) - A finger on Myrtis Henderson’s left hand is stuck in a bent position, a cyst on the tendon freezing any motion.

Henderson is a long-time patient of Dr. Jeannette South-Paul at the Matilda Theiss Family Health Center in the Hill District. South-Paul has helped her keep control of her diabetes, but the finger is another matter.

“The only thing that is going to help that is a surgical procedure,” South-Paul told Henderson, an unemployed pre-school teacher, at a recent appointment. “And until you have insurance, I can’t help you.”

Henderson, 45, is one of many patients who fall into a yawning gap in the health safety net. They need specialty care but are unable to get it because they don’t have insurance or have inadequate insurance. They either can’t get a specialist to accept them as a patient or can’t afford to pay upfront for the visit.

The specialist gap exists because few clinics for low-income patients have specialists on staff. The clinics often have no direct connection with the specialists, who are typically affiliated with hospitals or large practices. Even when they do have connections, they can’t always arrange timely, affordable specialty care.

Many specialists aren’t eager to take low-income people because they aren’t likely to be reimbursed well for the care of such patients, who are either uninsured, on Medicaid, or underinsured. While the Affordable Care Act opens up coverage to patients who didn’t have it before, some carry deductibles that are so high they still can’t afford to see specialists.

Moreover, even if the clinic can schedule an appointment, the patient might not end up going because there are upfront charges that put the appointment out of reach.

So the patients, as well as the clinics and doctors who treat them and recognize the need for specialty care, struggle with the cycle of sporadic, incomplete care.

Even if a patient begins a medical journey at a hospital emergency room, patients often find that unless their health problem is imminently life threatening, they are given minimal service, and they have to try to access a specialist on their own.

Back at the Theiss clinic, South-Paul tries to work the patchwork system to get care for the patients. She is chair of the department of family medicine at the University of Pittsburgh School of Medicine as well as a physician at Theiss, which is affiliated with UPMC.

“There is one orthopedic surgical place I know that does free procedures once a month,” she told Henderson. “But they only do hips. But I’ll do my best and see if we can find someone.”

“It just bothers me all the time,” Henderson said about the ganglion cyst on her middle finger.

“I wish I could just make it go away. But I can’t,” South-Paul replied. “I could get a (cost) estimate.” But it wouldn’t be a free or inexpensive visit, she said.

“I’ll wait to see if I can get in the (Medicaid) system first,” Henderson answered.

But two months later, Henderson still had not had the surgery because she had not yet qualified for Medicaid and could not afford to pay for it out-of-pocket.

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